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Wednesday, May 6, 2015

639-322 B.C.: Greek medicine was key

While medicine existed within the confines of other ancient civilizations, it came to a culmination in ancient Greece, particularly during the Age of Philosophers. With slaves were doing all the work, Greek citizens had time to ponder about the world around them and search for answers. They visited all the sages of the world, adding what they learned to the pantheon of Greek philosophy.

Among this wisdom was all that was known about medicine, and, in this way, during a period of only a few hundred years, Greek philosophy became the key to all medical wisdom. Those who had access to it would have the best physicians in the world. Those who did not would be left in the dark ages of medicine.

It all began with Thales of Miletus.

1. Thales of Miletus (639-544 B.C.): Garrison, in his 1922 history of medicine, said "he was taught under Egyptian priests, and taught that water is the primary element from which all else is derived." (1)

2. Anaximander of Miletus (611 B.C.): Garrison said "he mapped the heavens and made a successful prediction of an eclipse."(1) Perhaps he did this while working with Thales, because Sigerist credited Thales as accomplishing this feat. He believed the common elements were fire, air, water and earth, and their qualities were wet, dry, hot and cold. He believed they were all caused by a primary substance. From this the idea of two primary elements with opposite qualities was born. In a healthy person they were in balance. This theory would go on to become a significant part of Greek medical theory. (2, page 91) It must be assumed her that he did not create these elements and qualities, simply introduced them into Greek philosophy.

3. Pythagoras of Samos at Crotona (580-489 B.C.): Garrison said he studied in Egypt and it is probably from here that he "acquired his doctrine of the mystic power of numbers... (of which) the numbers three and four represent the worlds, the spheres, and the primordial elements" (earth, air, fire, water). He was also the first to associate the brain as the "central organ of higher activities." (1)

Sigerist said that while he believed in the elements and qualities, he believed the number was the most significant. He said:

Among the numbers, four played a significant part, for it seemed logical that two pairs of forces with opposite qualities would constitute an ideal balance, and we shall see that this view had a profound influence on medical theory, as had the Pythagorean doctrine of opposites of its dualistic form in general. These opposites were necessary to explain the harmony of the world. (2, page 97)

He believed that a balance of the internal qualities must be achieved in order to
maintain health, and this was maintained by "practicing moderation." When a person was unhealthy it was because the balance was disturbed. Health was therefore re-established physically by medicine, and mentally by music. (2, page 96-98)

Neuburger said some of the internal materials present in the body that needed to be balanced were cold, moist, warm, dry, sweet, and bitter. Empedocles would later limit these to four. (13, page 107)

As can be assumed with some degree of accuracy, he basically compiled all the wisdom of the sages of the world, and all the wisdom of the earlier philosophers of Greece, and created a large following who listened to his lectures. He even organized his followers into a school, and in this way he made philosophy popular in Greece, and is often given credit for giving birth to the Age of Philosophers in ancient Greece.

You can read more about Thales, Anaximander, and Pythagoras in this post. (1)

4. Anaximenes of Miletus (570-500 B.C.): He lived about the same time as Pythagoras. Garrison said he "assumed that indivisible matter (earth?), air, or fire respectively are the primordial elements."(1) Sigerist said he believed that of the elements of earth, air, fire and water, that air was the primary element. Of this, Sigerist said: (2, page 92)

He wrote a book of which one sentence has survived: "As our soul, being air, holds us together, so do breath and air surround the whole universe." (2, page 92)

He believed air was essential for sustaining life, and that it was also evident in the soul. He believed air was the primary element because he believed the others were "born from it through changes of density," said Sigerist, "through rarification (decrease in pressure) and condensation (increase in pressure)." (5, page 92)

Sigerist continued, "Rarified air became fire, and heat was generated in the process, while condensed air became water and finally earth, and produced cold. This was a logical explanation, and breath or air came to play an increasingly important part in biology." (2, page 92)

5. Heraclitus of Ephesus (556-460 B.C.): Similar contributions as Anaximenes.(1) Sigerist said he believed everything changes constantly, and therefore he believed the primary element was fire because it causes things to change. He believed fire produced air, water and earth. Fire, like war, causes strife, and the polar opposite of war and fire causes peace and unity (or balance).

Sigerist quotes him as saying: (2, page 93)

That which is in opposition is in concert, and from things that differ comes the most beautiful harmony." (2, page 93)

Sigerist said that, quoting Heraclitus along the way, "It is through opposites that we become aware of things. Disease 'makes health pleasant; evil, good; hunger, plenty; weariness, rest.' And everything in the world moves according to eternal laws. These very principles, unity of the world, eternal changing of all things caused by tension, and law and order ruling the world, were principles which proved to be strong stimulants to scientific research." (5, page 93-94)

6. Anaxagorus of Clazomenae (500-428 B.C.): He assumed the four elements (earth, air, fire, water) to be made up of as many parts or 'seed' as there are varieties of sensible or perceptible matter. (1)

7. Empedocles of Agrigentuin in Sicily (504-443 B.C.): Medical historian Edward Withington said he first mentioned the four elements, which would later influence Greek medicine, in the following poem: (7, page 45)

Listen, first, while I sing the four-fold root of creation,
Fire, and water, and earth, and the boundless height and the aether, For therefrom is begotten what is, what was, and what shall be. (7, page 45)

Withington explained that by...

"...substituting air for aether, this is the doctrine of the four elements, which Empedocles introduced into philosophy, and which, with the co responding four qualities, heat, cold, moisture, and dryness, and the four humours, blood, phlegm, black and yellow bile, lies the basis of Greek medical theories." (7, page 45)

"He introduced into philosophy the doctrine of the elements (earth, air, fire, water) as 'the four fold root of all things.' The human body is supposed to be made up of these primordial substances, health resulting from their balance, disease from imbalance. He holds that nothing can be created or destroyed, and that there is only transformation, which is the modern theory of conservation of energy. Everything originates from the attraction of the four elements and is destroyed by their repulsion, and he applies the same idea, under the forms of love and hate, to the moral world. Development is due to the union of dissimilar elements, decay to the return of like to like (air to air, fire to fire, earth to earth)." (1, pages 80)

The association between the four elements, four qualities, four humors, four basic organs, four seasons, and the four personalities can be seen by the following chart.

Element

Quality

Humor(Greek)

Combination

Organ

Season/

Cause

PersonalityTemperament

Fire

Hot

Blood/

Haima

Wet & Hot

Heart

Spring/EnergeticHopeful

Sanguine:

jovial, social

Air

Dry

Yellow Bile/

Choli

Dry & Hot

Liver

Summer/Diseases

Choleric: fussy,irritable

Earth

Cold

Black Bile/

Melanchia

Dry & Cold

Spleen

Stomach

Autumn/MelancholyDepressed

Melancholy:

depressed, gloomy

Water

Wet

Phlegm/

Phlegm

Wet & Cold

Brain

Lungs

Winter/

Coughs,

Colds

Phlegmatic: peaceful,laid back

You will see the significance of these played out in pretty much any history of mankind, and definitely in any history of medicine. While some contribute these to various different authors (Aristotle sometimes gets credit for the four elements, and Hippocrates for the four humors), it is the great Empedocles to which they may all be traced back to.

He believed that respiration, along with occurring through the lungs, also occurred through tiny pores in the skin. (13, page 108-109)

While Empedocles probably wasn't the first to conceive of the idea that something in the air inhaled was essential to life, he created the theory of pneuma. Pneuma was a substance in the air that contained a vital spirit. It flowed through the body by veins, providing life to the organs. It was responsible for movement, consciousness and perception.

8, Democritus of Abdera (460-370 B.C.): He was a student of Leucippus, and believed the mind and body were composed of corpuscles or atoms that were solids and unchangeable. In this way, he believed living things were made of these solid atoms as compared to the humours of Hippocrates. (14)

He believed the atoms were organized and arranged within the human body by a natural mechanism. (8, page 23) He believed that inflammation was an accumulation of phlegm. He believed the "widespread appearance of epidemic disease was... due to the disseminated atoms of shattered heavenly bodies." (13, page 110)

9. Hippocrates (460-370 B.C.): Prior to Hippocrates, methods of treating diseases were relatively simple, and taught mostly by word of mouth. However, stored in the Asclepions were votive tablets, and these contained lists of diseases and their cures. Hippocrates was the first to take all this wisdom and publish it into a compilation of 60 treaties called the Corpus Hippocraticum.

He believed air was inhaled, and this air contained pneuma. He actually referred to "breath" as the pneuma, and this pneuma (or breath) flowed through the veins, such as was noted by Empedocles. In health its flow through the body was unimpeded.

He believed that within each person was a combination of the following qualities: (14)

Acid

Saline

Acerb

Bitter

Mild

Insipid

Austere (14)

He said each of these was...

...possessed of different powers, in proportion to their quantity and degree of strength. All of these, when well united, and tempered by each other, are insensible to us, and do no injury; but if one should separate, and exist alone, it then becomes sensible, and ravages the system. It is the same with aliment. That which is improper for us, is either bitter, saline, acid, or too strong. (14)

Healthy food, such as bread, barley and cakes, "causes no uneasiness, or any separation of the particles of the humours of the body, and serving only to strengthen, nourish, and promote its growth. All these benefits arise from its well-attempered state, in which nothing predominates, nothing is irritating, nothing too strong. Every thing is reduced to a point, so as to be esteemed simple, homogeneous, and at the same time, of adequate strength." (14)

However, in the process of making such food, things like fire and water are employed, "each having its own peculiar powers and qualities. (The food) loses part of what it had, and what remains is a compound mixture." (14)
In this way, each type of food has its own particular qualities, such that bread has different qualities than cakes. Likewise, depending on how it was prepared, two different loaves of bread may have unique qualities. (14)

Hippocrates believed, therefore, that eating the wrong food, or too much of the good food, or food that was not prepared correctly, or food that was not part of that person's normal diet, might upset the unity and homeostasis within the body. This, in turn, leads to changes in the four qualities and four humors of Empedocles.

Medical historian Edward Meryon said Hippocrates must have studied the works of Democritus, who believed that a natural process usually worked to maintain a balance (homeostasis, unity) of the atoms. Hippocrates believed a natural process usually worked to maintain four qualities and four humors of Empodocles in order to maintain health. Hippocrates taught that any imbalance of the qualities or humors within a person was the cause of disease. (8, page 23)Nature worked to maintain balance in health, and to re-establish balance in sickness. He believed imbalances were generally the result of eating the wrong foods, or changes in the wind, or changes in the temperature, or changes humidity.His remedies were generally gentle, and merely worked to assist nature in the healing process. They included simple things such as getting plenty of sleep, taking a bath, eating healthy, and exercise.

His ideas would transform medicine from one of mythology and philosophy taught at the Asclepions, to a "distinct department of practical knowledge" that could be learned by anyone. (9)

10. Plato (427-347 B.C.): He was a student of Socrates, and became famous for recording the wisdom of the great philosopher. He then became a famous philosopher himself. As was normal for the era he was born into, he was educated in all the knowledge of the day, including medicine.

Garison said that his main contribution to medicine was that "In pathology, the plastic significance of the number four was combined with the doctrine of the four elements." This can be seen here (in parenthesis is our modern correspondence): (1)

hot + dry = fire (hydrogen)

cold + dry = earth (oxygen)

hot + moist = air (carbon)

cold + moist = water (nitrogen) (1)

These could also result in the following:

hot + moist = blood

cold + moist = phlegm

hot + dry = yellow bile

cold + dry = black bile

The various combinations of these resulted in both the aspect of disease and the action of the drugs used to treat them. Each person had a unique combination of these and maintained the equilibrium in times of health. Disease was a result of increases and decreases of any of the above. Health was re-established by making the necessary adjustments. (1)

Plato believed in the Pythagorean Theory of Opposites, although he also believed there was a "third element mediating between a pair of opposites." He believed the soul completed "the human trinity of body, soul and spirit." (12, pages 2-4)

He believed the body consisted of a soul with three parts: (11, page 23)

Rational Soul: Created by the brain

Animal Soul: Created in the chest and is responsible for emotions and passions

Vegetable Soul: Created in the abdomen and controlled physiological needs (11, page 23)

While Plato didn't create any of these ideas, he helped to keep them alive by his fame. He would also relay this wisdom to his famous pupil, Aristotle.

11. Aristotle (384-322): He was born in Stagira to a wealthy family. His father, Nicomachus, was personal physician to Amyntas, king of Macedon. He probably learned quite a bit about medicine from his father before being instructed by Plato when he was 17. (6, page 3)

He would spend about 20 years in Athens as a student at Plato's academy, and then as a teacher. Some speculate he left after not being chosen as Plato's successor upon Plato's death in 347 B.C. Some speculate the reason Aristotle was not chosen, and why he left Athens, was because Aristotle was known to debate and disagree with Plato. He moved from Athens and continued his work elsewhere. (6, pages 3-5)

Regardless, he basically supported the same ideas regarding medicine as Plato. He believed in the four elements, qualities, and humors. He believed that a balance or imbalance of these determined health and sickness. (1)

While he believed in the elements of Empedocles, he attempted to add a fifth element that he called aether, a substance that made up what was seen in the sky at night, such as the stars, sun, planets, comets, etc. He was not the first to write about the elements and their qualities, although by the fame he acquired by being the instructor of Alexander the Great, he was able to increase public awareness of them.

While he was not a physician, and is known mainly for his contributions to philosophy, he did make some significant contributions to medicine. Considering he was unable to dissect human beings, he spent most of his time at the dissecting table studying plants and animals. He was known for his faith in nature, claiming that "Nature does nothing uselessly." (5)

12. Erasistratus (304-250 B.C.) He was among the first Greek anatomists. He was the beneficiary of the new city, Alexandria, created by Alexander the Great. After Alexander died before he was 32 years old, Ptolomy decided to make Alexandria the leading place of wisdom and science in the world, so he gave the physicians at Alexandria permission to dissect human beings. Among these physicians was Erasistratus, who discovered and learned much about the inner workings of the human body. Some say he even went as far as to dissect living human beings, but all in the name of advancing science and wisdom.

He disregarded the idea the four humors caused disease, and believed that diseases like pneumonia were caused by changes in the body, such as inflammation of the lungs. This is the type of wisdom that might have been expounded upon if it wasn't considered sacrosanct to dissect the human body through much of the ancient world.

13. Herophilus (335-280 B.C.): He was the other leading physician at the school of Alexandria, and he likewise participated in dissection of the human body in a quest to improve wisdom and science. Unlike Erasistratus, he supported Hippocrates and his humoral ideas.

14. Galen: He was born during the Roman Civilization, although he still lived in Greece. He lived in Pergamum, a city that was ruled by the Romans, but that still lived under Greek culture. Galen learned from all the above physicians, and he basically combined the works of all these great men, particularly combining the theories of Hippocrates with the anatomical discoveries of Erasistratus and Herophilus.

He believed in the humoral theories of health and sickness of Hippocrates. However, while Hippocrates was not concerned with anatomy of the body, Galen came up with theories of how each organ participated in the organisms life giving process.

Galen also believed in the Aristotelian idea that nature makes no flaws, and perhaps from him Galen obtained his belief that God created only perfect human beings, and therefore each part of the body had a perfect function.

Through his writings he described the faculties of nature, whereby each part of the body (veins, arteries, organs, etc.) performed a distinct function in order to maintain life, health and longevity.

He absorbed the idea of Plato of the power of three parts of the soul, although he referred to them as spirit.

Natural Spirit: Formed in the liver and flowed through the body by veins to the various organs.

Animal Spirit: Formed in the brain and responsible for sensation and intelligence

Vital Spirit: Formed in the heart when air mixed with blood, and flowed through the arteries to the various organs. It consisted of passions.

He believed the person ingested food, the food was cooked in the stomach, turned into chyle, sent to the liver by veins, and turned into blood in the liver. The liver added natural spirit and nutrients to the blood, and sent it to the right ventricle of the heart to be purified. The blood was turned into a light, frothy substance so it could enter the lungs, and returned to the right ventricle of the heart as purified blood that ebbed and flowed through the entire system to provide natural spirit and nutrients to the body through the veins.

Some blood from the right ventricle was transferred to the left ventricle by invisible pores. This blood was mixed with air that was inhaled by the lungs. Since the heart was hot and controlled the temperature of the body, the cool air was needed to cool the heart. Air also contained pneuma, and so when the air and pneuma mixed with blood in the left ventricle, it formed vital spirit. This substance was responsible for the passions of the person, and was transferred through the body by the arterial system.

Some arterial blood went to the brain by vessels from the heart to the brain. Here this blood was mixed with animal spirit and sensations and intelligence. These were transported through the body by the various nerves.

His ideas of health and healing were similar to Hippocrates, although he believed changes that occur within one organ can effect the body as a whole. For example, asthma was caused by increased phlegm in the lungs, epilepsy was caused by increased phlegm in the brain, fever was caused by increased blood, etc.

His remedy was to treat contraries with contraries, or to treat whatever was the suspected cause with the opposite. If someone has too much phlegm, for example, Galen may have the patient drink a purgative or emetic to expectorate the excess phlegm.

Since Galen was the very last of the Greek and Roman physicians when Rome collapsed, and because he wrote so much about it, his works continued to be worshiped for greater than the next 1,500 years. Basically, Greek medicine survived the dark ages through the works of Galen.

During the Middle Ages the Catholic Church accepted the medical writings of Galen, perhaps because he believed that God created only perfect human beings. This fit into the Christian belief that god made no flaws. During this time, anyone who spoke out against the writings of Galen was greatly ridiculed, and sometimes severely punished, sometimes with death. (4, page 113)

So during the dark ages of medicine, Galen became a god, of sorts, of medicine. His works were like the Bible to physicians. In this way, Greek medicine was the key, or the foundation of all medical knowledge. It would only be from using this key that any future advancements in medicine would be made.

References:

*The above characters and descriptions are taken from Fielding Hudson Garrison's book, "An introduction to the history of medicine," pages 80-83. The same information can be obtained in many medical history books, with Garrison's, in my opinion, being the most pithy for our purposes.

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John Bottrell is a respiratory therapist. He's a featured asthma and COPD writer for asthma.net and copd.net. He's the creator and occasionally writer for Respiratory Therapy Cave, the #1 respiratory therapy blog. He's an avid historian and creator of Asthma History. His blog posts have been featured in various newspapers, such as the Chicago Tribune. He has previously been a featured asthma/COPD writer for Healthcentral.com and asthma writer for Answers.com.